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Access to Mental Health and Substance Abuse Providers (July 10, 2006)

Saturday, July 1, 2006
Health Care Bulletin #120

Bulletin HCA-120

Access to Mental Health and Substance Abuse Providers

The 2006 session of the Vermont legislature passed and Governor James Douglas signed into law, House Bill 404. This law is commonly known as or referred to as "any willing provider" for mental health and substance abuse care. The law prevents insurers from closing their provider networks. It requires that insurers admit into their networks any licensed mental health or substance abuse provider who is: (1) within the plan's geographic coverage area and (2) willing and able to meet the terms and conditions for participation in the plan. The Act is an amendment to 8 V.S.A. § 4089b(b) and is effective as of July 1, 2006.

The "terms and conditions for participation established by the health insurer" may be individual and specific for each insurer and/or health insurance plan. They can include credentialing processes whereby professional qualifications, licensure, continuing education and references are evaluated against established criteria; contract terms; administrative procedures; participation in quality improvement initiatives and negotiated reimbursement rates. BISHCA, through other aspects of its regulatory activities, obtains information about and evaluates the credentialing processes of managed care organizations.

Insurers are expected to process mental health and substance abuse providers' applications for admission into their provider networks in conformance with the new law. Applications may not be rejected on the basis that the insurer already has a sufficient number of participating providers available to its members within a specified geographic area. Rather, each provider applicant must be considered for network participation regardless of the number of providers who already participate. BISHCA expects that insurers will require some time to process applications and perform credentialing and other appropriate checks; however, the time taken must be a reasonable period of time and decisions on applications should not be unduly delayed.

If providers are not willing to meet the "terms and conditions established by the health plan," the insurer is not obligated under this law to allow the provider into the network. Disagreements about reimbursement for services rendered, administrative requirements for network providers and other reasonable terms of a provider-insurer relationship may cause providers not to join the network, despite its mandatory geographic opening. Good faith failures to come to agreement on the terms of a provider-insurer relationship are not likely to constitute violations of the law or to serve as a basis for regulatory action.